I s s u e 2 2 0 2 0
Hope and Resilience
The Editorial Board
Upper row: Óttar Gudmundsson, Hanna Tytärniemi Center row: Ola Marstein, Marianne Kastrup
Bottom row: Ramunė Mazaliauskienė, Hans-Peter Mofors
Dear colleague,
We are indeed living in different and special times. Never has any of us experienced these new circumstances when our lifestyles are changed, both privately and at work.
Nothing is anymore the same.
These new challenges affect us differently. To some, it just means a new way of dealing with everyday life. To others, life becomes more or less a nightmare. Many people suffer from loss of jobs, and others suffer from the new, imposed isolation and loneliness. Some even develop psychiatric symptoms, such as anxiety, insomnia and depression. Unfortunately, many patients will these days wait long before seeking help, resulting in more severe symptoms upon arrival to health care units. We do not yet know how this will change the incidence of suicide in the population.
In other words, life is changed and the future is less predictable than normal. This means a stress to many of us. The ability to deal with stress differs a lot between many of us. This is how resilience is defined. Some will deal with new demanding situations well. To others, it will be detrimental.
As the new negative situation emerges, some will over time lose the feeling of hope, experi- encing more and more of despair. This is a mechanism that no doubt contributes to psychiatric illness – and to suicide.
In this issue of The Nordic Psychiatrist, we have chosen to focus on these interesting fields:
Hope and Resilience. Fortunately, there are so many colleagues of ours who have much interesting to say about this. Therefore, I can promise you a quite interesting reading.
As always, you will also find many other well written articles and comments.
It is, as always, a joy and an honor for me to be part of creating this journal for all our colleagues in the Nordic Region.
Take care of yourself – and your beloved ones!
Hans-Peter Mofors, Editor
Hans-Peter Mofors
NORDIC JOURNAL HISTORICAL ASPECTS HOPE AND RESILIENCE
ON EDUCATION
MEDICAL COMMENTS
A WEEK IN PSYCHIATRY NORDIC CONGRESS OF PSYCHIATRY Editor
Hans-Peter Mofors 3
Nordic Congress of Psychiatry 2021 VIRTUAL - Connecting Minds
Marianne Kastrup 6
Nordic Congress of Psychiatry VIRTUAL - Connecting Minds.
Introduction to plenary speakers 8 Resilience in times epidemic
Óttar Gudmundsson 10
About the importance of the environment and the individual's resilience. Interview
Hans-Peter Mofors 12 The hope
Óttar Gudmundsson 14
Resilient organization supports smooth working Arja Ala-Laurinaho, Anna-Leena Kurki, Hanna Uusitalo 15
Religiosity and faith in God affect hope and resilience in mental illness
Øystein Elgen 17
Spiritual care in secular healthcare settings
Ricko Damberg Nissen, Niels Christian Hvidt, Frederik Alkier Gildberg 19 Hope, community and communities of hope
Knut Tore Sælør 21
Hope and resilience in psychoterapy
Per Anders Øien 23
Traumatized Refugees: How to support their resilience. Interview
Marianne Kastrup 25
Refugee children and youth – risk and resilience
Edith Montgomery 27 Hope and Resilience
Piret Visnapuu-Bernadt 29
Resilience against mental illness – the role of genes and the environment
Olav B. Smeland, Ole A. Andreassen 32
Snorri Sturluson and the detachment theory
Óttar Gudmundsson 34 The great loneliness
Peter Strang 36 Resilience
Cato Zahl Pedersen 39
The First National Suicide Prevention Program in Finland. Interview
Hanna Tytärniemi 41
Effect of training general practitioners. Interview
Marianne Kastrup 43
Simulation Teaching of Addiction Medicine in University of Turku.
Interview
Hanna Tytärniemi 45
Psychedelic psychotherapy
Tor-Morten Kvam 47
Practical Aspects of Esketamine Use. Interview
Ramunė Mazaliauskienė 49
A case of Post-Covid Encephalopathy
Maher Khaldi 51
A Modest Art of Table Making: Week of the Manager during the Times of Pandemic
Ramunė Mazaliauskienė 51
Highlights from the Nordic Journal of Psychiatry
Martin Balslev Jørgensen 55
Editorial Committee
Hans-Peter Mofors, MD.
Psykiatri Nordväst, Stockholm [email protected]
Óttar Gudmundsson, MD.
Psychiatrist. Landspitalinn, University Hospital, Reykjavik Iceland
Marianne Kastrup, MD., PhD.
Specialist in psychiatry
Hanna Tytärniemi, MD.
Consultant psychiatrist, Oulu and Lapland, Finland
Ola Marstein, MD.
Practising psychiatrist, Special advisor to The Norwegian Psychiatric Association, Oslo
Ramunè Mazaliauskienè, MD.
Lithuanian University of Health Sciences, Psychiatric clinic
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Hope and Resilience
Nordic Congress of
Psychiatry 2021 VIRTUAL - Connecting Minds
Interview with Hanna Tytärniemi, chair of Organising Committee
When the planning of the Nordic Congress of Psychiatry 2021 started the world had not heard about COVID-19
True. We started already in 2017 in the Finnish Psy- chiatric Association to discuss what image we wanted to convey with the next Nordic congress, choosing the slogan and starting to think of excellent plenary speakers. Personally, I am involved in the organising committee of the congress and professor Tiina Paunio is the chair of the scientific committee.
Our original plans have been built around the typi- cal structures of earlier Nordic Psychiatric Congresses with a Finnish twist. For instance, in our original so- cial program we wanted to provide the participants with a glimpse of what is particularly Finnish, intro- ducing Finnish culture, design, and architecture with a Finnish design tour. We had some more playful and casual social program planned as well, related to some peculiar "World championships" related to Finnish culture. Let's see how we will integrate these plans in our NCP2021 VIRTUAL program.
So the pandemic has changed your plans?
Since the spring of 2020 we have all seen the dramatic changes related to COVID-19. In the organising com- mittee we have had to consider the pros et cons for having a face-to-face congress. There are very many factors to include when taking a final decision, and in November 2020, we had a clear opinion to organize the Congress in virtual surroundings. We are now up- dating our plans as we speak!
Meeting colleagues and friends in real time and inter- acting with colleagues from other countries allows you to get to know other cultural aspects and get an oppor- tunity to develop new friendships and maybe plans for future collaboration. I think that this is a part of face- to-face events that most of us cherish. In NCP2021 we are now doing our best to facilitate the same in virtual surroundings. We just have to challenge our beliefs re- lated to the traditional way of doing things.
Marianne Kastrup
Has the pandemic had any influence on the interest from the potential participants?
The whole world is right now living in a time of un- certainty, and not knowing for how long this will con- tinue. Thus, many may have been uncertain about their possibility to travel and join the face-to-face congress in Helsinki. We wanted to commit ourselves to the virtual congress so that each potential partici- pant would know in advance that there will not be a cancellation because of restrictions related to the pandemic.
Do you see some advantages with going virtual?
Indeed, there are several advantages. First of all, we can ensure that the congress will be held and not cancelled or postponed related to the pandemic.
Also, safety is not an issue if we are still combating COVID-19, so all participants from whichever coun- try can join the event safely. There are obvious eco- logical positive consequences related to less traveling and less use of materials. Another advantage is a more economical participation fee and absence of travel and accommodation expenses, so many more can afford to participate. It is also easy to combine par- ticipation with continuation of your normal life with family, hobbies or other domestic interests. You can even sleep longer in between congress days when there is no need to travel or move between locations.
You can even do stretching or yoga exercises or go for a walk in between the sessions. This can definitely
support the learning possibilities. As a Finn I can also relate to introverts who may find it easier to attend a virtual event compared to a crowded live conference.
So, we may end up by having a different kind of audi- ence compared to many previous congresses.
A virtual congress challenges the concept of a con- gress. We have to think of new ways to structure the congress, prepare a more condensed version but also think of creative ways to include the audience, orga- nize different "chat rooms" and ask presenters to be innovative in their presentations.
I hear it that you are quite optimistic when it comes to having a virtual event?
Yes, we have rolled up our sleeves, and our goal is to find new ways to attract psychiatrists to join together in a Nordic meeting and experience being part of a Nordic psychiatric community.
So join the congress is my message!! Hanna Tytärniemi
Psychiatrist. Chair of Organising Committee for NCP2021 Virtual
Nordic Congress of Psychiatry 2021 Virtual - Connecting Minds
Introduction to plenary speakers
Hoping that a short introduction to the plenary lectures of the scientific program will tempt you to join the congress and be part of this unique Nordic event.
For further information please go to www.ncp2021.fi
Professor Pim Cuijpers, Amsterdam will give a plenary lec- ture on: The future of psychotherapy
He is specialised in conducting randomised controlled trials and meta-analyses on prevention and psychological treatments of common mental disorders across the life.
He has more than 900 publications and he is on the Thom- son-Reuter Web of Science lists of the ‘highly cited re- searchers’ since the first edition of this list in 2014.
Professor emeritus Ian Michael Goodyer, Cambridge will hold a ple- nary lecture: Adolescent Mental Health: From Brain to Therapeutics.
As a Child and Adolescent Psychiatrist his research uses different ap- proaches to measure the effects of the social environment on cogni- tion, brain structures and mental disorders. The therapeutics research has resulted in a new brief psychosocial intervention (BPI) adopted by NICE UK as a treatment for unipolar Depression in Adolescents.
He has received 3 awards and was elected a Fellow of the Academy of Medical Sciences in 1999 and awarded the OBE for Psychiatry Re- search in the New Year Honours list 2017.
Plenary speakers:
Professor Merete Nordentoft, Copenhagen will hold a plenary lecture titled: Improving treatment of people with psychotic illnesses: lessons from randomized clinical trials She is an expert in suicidal behavior, and a pioneer in early intervention in psychosis. She was PI for many large ran- domized clinical trials, evaluating the effect of psychosocial intervention, of which the Danish OPUS trial (specialized assertive intervention in first episode psychosis) is the most well-known. She received the award “Global Excellence in Health” in 2012 and 2016; the Richard Wyatt Award in 2016, The Marie and August Krogh Award in 2017, and The Danish Medical Association’s Honorific Award in 2018.
Riitta Hari is Professor Emerita, Aalto University, Finland. Her plenary lecture is titled: Brain basis of social interaction.
Her research is on systems-level neuroscience and human brain imag- ing, and has provided fundamental insights into human sensory, motor, cognitive, and social functions in both healthy and diseased individuals.
She has received honoris causa doctorates in science (2003), medicine (2005), and technology (2016), and is Academician of Science in Finland since 2010 and member of the National Academy of Sciences USA since 2004.
Dan Chisholm is Programme Manager for Mental Health at the WHO Regional Office for Europe Copenhagen.
He will give a plenary lecture: Public mental health needs and re- sponses in the context of COVID-19: a blueprint for the future?
He works with WHO Member States and other partners to develop and implement national mental health policies and plans, as well as provide guidance, tools and advocacy for the promotion of mental health and the development of prevention, treatment and recovery services across the life-course. His main areas at WHO included development and monitoring of global mental health plans and ac- tivities, technical assistance on mental health system strengthening, and analysis of the cost-effectiveness of strategies for reducing the impact of mental disorders.
Mark Daly is Director of the Institute for Molecular Medicine Finland and with affiliations at the Harvard Medical School, Bos- ton. He will hold a plenary lecture on: Genetic architecture of psychiatric traits and disorders - shared and specific biological mechanisms.
His research focuses on the development and application of sta- tistical methods for the discovery and interpretation of genetic variation responsible for complex human disease. Further he has made major contributions to gene discovery in several disorders and is a co-architect of the FinnGen project, a landmark effort to integrate medical registry data with genomic data in 10% of the Finnish population.
He coordinates the leadership team of the COVID-19 Host Genetics Initiative (HGI) (https://www.covid19hg.org) to bring together the human genetics research community to generate, share, and analyse data to define the genetic determinants of COVID-19 susceptibility, severity, and outcomes. He has 478 peer-reviewed manuscripts and has been listed by Thompson ISI/
Science Watch in 2008 and 2010 as one of the top ten authors ranked by number of high-impact papers.
Resilience
in times epidemic
The Corona virus has spread throughout the world at high speed over the last few months. People´s life has totally changed. Existence is no longer foreseeable;
instead it is subject to constant change. Travels that had been planned have had to be cancelled; social gatherings and family celebrations have been postponed. The appearance on the street has changed, as a large number of people are walking about with masks covering their nose and mouth as predicted once upon a time in a future literature.
Óttar Gudmundsson
The virus causes both acute fear of being contaminat- ed and fear of long lasting inability to provide for one- self. The impact of the virus on the economy causes unemployment and various and vast difficulties. Psy- chiatrists see changes in people’s mental health that may be traced to the stress that follows this epidemic.
The uncertainty is like a heavy weight upon the shoul- ders of society. Everyone, young and old, can become ill. Making long-term plans is not possible, which in turn people find to be terrifying.
Many have written about the impact of long-term stress and pending risks to people’s mental health.
The Austrian physician, Dr. Victor Frankl, survived Auschwitz and wrote about his experiences. He ad- dressed, among other things, people’s reaction to im- mediate danger that threatens their entire safety. Terror turns into long-term stress and immeasurable fright.
Usually, the first reaction is denial and shock. Such re- action was common at the beginning of the epidemic.
People minimized the impact of such illness, blindly believing in their own health. Many refused to change
their ways and believed that the epidemic was not spreading to any major extent. The more denial, the greater the blow when people realized the gravity of these illnesses.
According to Dr. Frankl, the next phase of such reac- tion to a pending terror and difficulties is apathy. Peo- ple face the fact that the virus exists, however, grad- ually learn to live with it. The terror remains, but life continues. People begin to abide by antisepsis rules and believe that this threat is here to stay. This is quite visible in the western part of the world where people accept the decisions of the antisepsis authorities; deci- sions that limit people’s personal freedom. They allow themselves to be confined indoors for weeks on end and consent to all kinds of limitations to their freedom of travel and gathering.
The third phase is characterized by people losing their personality features and melt in with the situation. At this phase symptoms like anger, bitterness and accu- sations bloom. People lose their personal characteris- tics and everything evolves around the virus. All inter-
ests and conventional topics of discussion disappear when the virus takes over everything. This is quite visible in all news reporting, as the news media cease their reporting about the conflict in Syria or elections;
instead they focus on the number of infected people and the mortality rate.
Dr. Frankl defines certain personal distinctive features that are helpful in getting through this kind of diffi- culties. The most important one is to have some goal or purpose in one’s own existence. People who have goals find it easier to tackle various adversities. Those experiencing much lack of purpose in their existence find it more difficult to bear the stress caused by the Corona virus or by other related problems. This is particularly helpful at the third phase of reaction, i.e.
at times when the virus appears to be literally taking over all normal existence.
The different reaction by individuals towards the virus illustrates this well. People who have a difficult dispo- sition find it hardest to adjust to the threat caused by the virus. Individuals who suffer depression or com-
pulsion – obsessive behavior, have difficulty tolerating the extensive changes caused by the virus. People with personality disorders with persecution or paranoia find it hard to tolerate such environment of uncertainty and soon withdraw into a world of conspiracy theories.
Such individuals put the virus in context with attempts by evil forces for world domination; forces seeking to oppress mankind into obedience.
This latest epidemic clearly shows how the reaction of people to this kind of stimulus is always similar, irre- spective of whether this involves serious illness, natural disasters or warfare and persecution. Any kind of stress thus causes changes in man in a foreseeable manner.
Óttar Gudmundsson, MD Psychiatrist. Landspitalinn, University Hospital, Reykjavik Iceland
Few people in Swedish psychiatry are as associated with knowledge about stress and exhaustion as Marie Åsberg. Her psychiatric research spans over decades, and has from an initial neurobiological focus over the years focused more on the individual's symptoms related to their psychosocial context.
About the importance of the environment
and the individual's resilience
Hans-Peter Mofors
Interview with Marie Åsberg
Like so many senior people these days, Marie has been in quarantine for months, why we meet for an interview over a video link, a communication form many of us in a short time have become accustomed to. To my surprise, it works almost as well as a phys- ical meeting.
Our conversation theme is about both hope and re- silience. –“Stress” as a concept means that you are exposed to pressure, but later return to your normal state. Basically, stress is something positive, some- thing that makes us mobilize in pressured situa- tions, for fight or flight. “Resilience” however, can more be described as extensibility and the ability to stretch back, in a humane context the possibility of recovery.
Interestingly, resilience is a concept that for long has been used in the military, and more with a focus on how to increase the soldier’s resilience. In our medical profession, we have far too long focused too much on the role of the individual, and his or her vulnerability. Marie draws a parallel with coal workers in the past, who used to bring a canary down into the mine. When the bird stopped singing
or died, it was understood that the air was not favor- able, and therefore time to get up into the fresh air.
Somewhat later the workers went down again (with a new bird?).
There are indeed similarities with how we look at hu- man health. When an individual falls ill from stress at work, employers sometimes gets rid of that person and simply hire another one. There is a danger in focusing on the importance of the individual for falling ill from exhaustion. In fact, several of the personality factors that predispose to this are traits (sense of responsibility, empathy, moral sensitivity for example) that actually are desirable, says Marie.
Marie Åsberg Professor Emeritus KI
Researches stress and fatigue, suicide - KIDS KI at DS.
Educational materials in psychiatry
that long-term stress is linked to cardiovascular dis- ease, but few know that there is also a link to the development of cancer. Chronic stress changes our biology, but in what way? More research is needed to understand the causes of this. It is quite clear that sleep and security in a group are factors that are pro- tective against stress - and also promote resilience.
Marie usually refers to the image of young Swedish soldiers in Afghanistan, who in an extreme situation are able to seek security with each other and in the middle of it all manage to fall asleep.
Some circumstances contribute to transform stress to something negative and dangerous: Such as when we suddenly are overwhelmed by stress, when our coping mechanisms simply are not enough to han- dle the situation. Some people will then respond with an adjustment disorder or with post-traumatic symp- toms. But not all.
Prolonged stress increases the risk of fatigue syn- drome. It is precisely the time aspect and the absence time for recovery that is central to the exhaustion pro- cess. Experiments on both animals and humans have shown similar structural findings on the hippocam- pus, prefrontal cortex and amygdala. This is probably due to an impact on centers for stress management.
Thus, in a stress context, resilience then means the ability to find factors that protect against fatigue.
Some people have the ability to relax in chaotic situ- ations, especially with preserved sleep. These people are almost by definition more resilient.
The positive personality traits such as accuracy, ambi- tion, sensitivity and empathy are highly appreciated.
In this way, they are not what we normally would refer to as vulnerability factors, but can still be perceived as such, as people with these traits are more suscep- tible to be exploited in some working environments.
Therefore, it is more the work context itself we must focus on, rather than on the individual's presumed fragility. -How can workplaces be designed to identi- fy and prevent chronic stress? It is not the canary that is basically fragile, it is the air it breathes that is toxic.
personality traits are more prevalent. However, it is the working context itself that has become toxic to them.
The typical health care situation consists of a large group of people working intensively towards the same goal. Some of these persons take too much individual responsibility over time.
About 25 percent of people who have been on sick leave for exhaustion relapse later. As in so many other contexts, comorbidity plays a major role. Personality disorder, ADHD and substance abuse are prognostic unfavorable factors.
We also have time to talk a little about the importance of hope. Depression is the condition most commonly associated with hopelessness and can also be suicidal.
- One of the doctor's tasks is to be the patient's substi- tute hope, says Marie, with many years of experience of depression patients. Even in depression, resilience seems to be important. Some people find it easier to endure difficult feelings, to endure in the midst of suf- fering. Knowing this, new therapeutic methods have been developed, with a focus on treating and relieving the pain of depression.
The hope
The most famous football match of the Icelandic history of sports took place in Copenhagen in 1967 between Denmark and Iceland. The Danish team promptly seized total control on the football field, scoring one goal after the other. The Icelandic team leader, however, did not change the structure of his team; instead continued to have his players in offensive mode. The score at mid-game was 6 to 0 and the situation moved from bad to nightmarish. When the position was 9 to 1 goals, Iceland managed to score its second goal. This changed nothing, however, and the game ended with 14 goals versus 2. The biggest scandal in the Icelandic football history was a fact!
Viewing this game it is easy to realize that the Icelan- dic players soon lost all hope. The defense was nei- ther here nor there and the players hung their heads in defeat. Any will of fighting disappeared from the team! The Danes were encouraged by a screaming audience of thousands and needless to say the Dan- ish players got stronger as the game progressed. The spectators yelled “twenty-to-two”, i.e. 20 goals ver- sus 2, to humiliate and break the Icelandic team. The Danish players shone with self-esteem while the Ice- landic team lost any confidence they may have had.
This game clearly illustrated the importance of hope and optimism in sports and in life. If you lose hope, the battle is lost!
The Greek mythology emphasizes the importance of hope. Prometheus stole the fire from the gods. Zeus took revenge by sending Pandora to Earth to Pro- metheus’ brother. She brought a box with her which she was strictly forbidden to open. Pandora did not abide by the instructions and lifted off the lid, letting out all kinds of misery, epidemics, death, capricious weather, and the most unbelievable plagues that spread throughout the world. She hurriedly replaced the lid, leaving only hope behind. Other problems es- caped out of the box, causing difficulties and harm for mankind. The message of this story is that hope is necessary for us all in order to survive all kinds of problems we are faced with. We need to have goals that make our life worth living.
Hope is essential in the struggle against disease. If a patient has lost all faith in his or her treatment and be- lieves that recovery is not around the corner and never will be, the struggle becomes more difficult.
Hope contains a promise of hard times not lasting for- ever; instead they are but a temporary situation. All re- ligions emphasize the value and importance of hope.
Even death is not final! Religion promises life and sal- vation after death - at a time when everything is to be finished.
Hope is therefore of utmost importance to human life and existence.
The above must be reflected upon in these Covid times.
Many people have lost hope and no longer believe that a normal situation with unlimited freedom of travel and gathering will ever return. Covid 19 is one of these ep- idemics that came out of Pandora ’s Box. It is of great importance that we do not lose the hope that remained behind in the box.
Óttar Gudmundsson
Resilient organization
supports smooth working
Organizational resilience is a collective capability which is built on organization’s culture, structures, processes and tools, rather than an aggregate of resilient individuals with good coping strategies. In resilient organizations employees have shared understanding of the entire work system. They are familiar with collective problem-solving practices and equipped with tools to find ways to succeed in emerging situations. This article is based on studies the authors have conducted in Finnish Institute of Occupational Health.
Arja Ala-Laurinaho, Anna-Leena Kurki, Hanna Uusitalo
Working in the midst of surprises
A smooth and predictable workday is a rarity nowa- days. Tasks and duties are scattered to a variety of em- ployees across different departments and even organi- zations, as work is done in different kind of networks and production chains. Information needed at work is stored in databanks, processed with automatic al- gorithms and shared further via integrated IT systems.
This kind of connectedness leaves lots of room for sur- prises and unexpected occasions in everyday work.
These features of work are examples of effects of dig- italization. Though some of the effects cause distur- bances and drawbacks in the work, many of them are positive, allowing efficient distribution of work, good situation awareness based on shared information, and collaboration and ideation across geographically dis- tributed units. COVID-19 pandemic has highlighted many advantages of digitalized work processes, al- lowing working even during times of restrictions and quarantine.
Resilience needed!
In order to get full advantage of digitalization, orga- nizations need to renew their traditional, hierarchical practices and develop new ways of organizing agile working. Organizations need more resilience both in everyday actions as well as in longer term development of their business and operating models. Resilience is about coping with unanticipated situations, learning from experiences, and adapting and renewing activ- ities in accordance with changing circumstances. In
resilient organizations structures and practices support individuals and teams to act both proactively and reac- tively in unexpected situations, and seize collectively the emerging future possibilities.
How to support organizational resilience?
Based on our research, we emphasize the importance of shared understanding of the entire work system for resilient action. Such understanding lays grounds for collective efforts and practices and helps employees consistently respond to changes and challenges in their work.
For example, a practical aspect of digitalization is im- plementing different kind of IT systems in organiza- tions, which requires changes in the entire socio-tech- nical work system. The implementation phase is often filled with interruptions, disturbances, and unexpect- ed incidents in the use of the new IT system, causing feelings of stress and even despair. According to our research, however, IT implementation process can be managed in a way that helps employees to perceive the entire organizational change, supporting also col- lective learning and problem solving in the use of the IT system.
Achieving a fluent and smooth use of a new IT sys- tem requires that the organization supports learning in three different aspects: the employees need to know the features and functions of the IT system (“what is it about”); know how to use it as a tool in their own work (“how to use it”); and understand the meaning
of the IT system as part of the emerging new service and production system, or operating model of the organiza- tion (“why to use it”). Formal training and e-materials, peer-to-peer and supervisor support, and workshops are examples of practical means for such learning. Notice- able is that this learning should start with creating un- derstanding of the new organizing and operating model:
such understanding creates grounds for employees to take active role in the continuous, interdependent de- velopment of work tasks, work processes and IT systems as tools, and helps them to connect the single features of IT system into their own renewed work.
In the core of resilient action are, however, understand- ing the variance of daily work and collective learning and development concerning work processes. Such re- silient capability is embedded in the everyday practices, tools and structures, and also fosters resilience in sudden situations as well as in larger reformations as described above.
An example of important practice is organizational problem-solving methods that may hinder or support re- silient ways of working. Typically, the daily problems are solved by individual employees. The employee might, for example, ponder the situation, test the solution, or
use handbooks, instructions or google. However, building resilient ways of working requires collective problem-solving practices: space and time to discuss the problematic work situations and build the con- textual knowledge within the team and collaboration network. This enables wide-ranging and multisectoral solutions that maintain resilient ways of working, which do not rely on the mere personal competences of individuals.
Resilience is putting collective learning into action Resilience as a collective capability comprises more than just a collection of resilient individuals with good coping strategies; it builds on organization’s culture, structures, processes and tools that support collective learning and creation of shared understanding of the changing reality and variance of daily work.
In resilient organizations employees are both encour- aged and equipped with tools to find ways to adapt to emerging situations and overcome challenges when work doesn’t run as planned or imagined. In this way, the employees are empowered to be resilient actors with coherent actions in the contemporary integrated work processes.
Anna-Leena Kurki, MA (Educ.), Senior Specialist, Finnish Insti- tute of Occupational Health.
Anna-Leena’s research interests are organizational learning and development in contemporary working life.
Arja Ala-Laurinaho, MSc, Lic.
(Tech.), Senior Specialist, Finnish Institute of Occupational Health.
Arja’s research interests cover digitalization of work, organiza- tional change and participative development.
Hanna Uusitalo, MA (Educ.), Senior Specialist, Finnish Insti- tute of Occupational Health Hanna is interested in resilience from the perspective of safety management and development of best practices to improve occupational health and safety.
Religiosity and
faith in God affect hope and resilience in
mental illness
Øystein Elgen
A young woman who has been treated at a District Psy- chiatric Center (DPC) for some time was referred to me.
She had experienced that her therapist at the DPC was not being able to talk about the patient’s faith in God. Like many others I have met as a psychiatrist, she said that she experienced that the therapist thought her faith in God was at best irrelevant to her illness. The patient, on the other hand, experienced faith as a crucial resource for living with the disease. I contacted her therapist, and we agreed to have a joint conversation, where the patient and I talked together about her faith and the disease, with the therapist present. My intention was to normalize and sim- plify the topic for the therapist, who afterwards expressed that she had learned a lot about the importance of what the patient's faith means as a resource for coping with the mental illness. The focus in a consultation is the person who asks the psychiatrist for help. We need knowledge, theory and methods. But these must never be more im- portant than the person - the patient - experiencing being seen, understood and met.
All human beings have an existential view, that is crucial in their lives. Some are aware of their existential values, others are not. The patient must be allowed to bring this view into the therapy room, even if it is unknown to the therapist. Population surveys show that the majority of the populations in the Nordic countries have a form of reli-
gious / spiritual belief, in a personal God or an impersonal force or meaning / destiny.
A great volume of research in recent decades has described that religious / spiritual beliefs have a great influence on people's hope and resilience, on the risk of people becoming mentally and somatically ill, and on how people cope with their suffering and illness. Furthermore, research has found that many patients want the therapist to open up for such topics to be touched upon, but that most therapists believe the patient is not interested in this, that it is irrelevant, or for their own personal reasons will not talk about religious beliefs.
We as therapists have a lot to gain if we take the patient's existential / religious point of view seri- ously. Already at the beginning of the first con- sultation I introduce to the patient that they can freely address what is essential in their life, even if they have faith in God that represents difficult challenges or that this is perceived as a resource.
Several times I have heard: "Can I do that? I have not experienced that I could in previous treat- ment, even though it is important to me».
Faith in God can lead to both poorer and better
At the Norwegian “Psychiatry Week” in March, a well visited session presented
clinical experiences and theory on the topic of religiosity, which is often neglected
by the secular therapists of today. Psychiatrist Øystein Elgen presents his thoughts
on this topic
mental health. There is a big difference in well-being, morbidity and life expectancy depending on whether the belief is positive or negative. By positive faith is meant the belief in a personal good God, who forgives and shows love and care. According to some studies, it gives an average of 10 years longer life expectancy than for those who think that God sees me and punish- es me (negative God-belief). The differences in mental health, hope and resilience to illness are found to be similar. There are many reasons why people with pos- itive, personal faith in God come out better regarding resilience to disease; a generally healthier lifestyle, of- ten close relationships, greater security, meaning and hope, and the possibility of a placebo effect, which faith in God is believed to provide. What is found to be effective in placebo is trust, which in reality is the essence of faith in God. Some research results found that when the influence of all such factors is removed, faith alone will still have a positive influence on illness coping. Personal faith also has a greater effect on hope and life mastery than "only" being part of a religious context. A summary of research and a brief description of the more than 18,000 articles on the connection be- tween religion and health (somatic and mental health up to 2012) can be found in the "Handbook of religion and health, 2nd edition". In the years since, almost 1000 articles per year have been added in this field.
Therefore, religious belief and existential views are im- portant topics to understand for the therapist who will help the patient to understand himself and his mental health, and explore his challenges and resources for coping. In the same way as with other topics that the patient addresses, the therapist does not have to have the same basis of life as the patient in order to take the existential issues and the patient seriously. Of course, it is not the doctor's existential point of view or pos- sible "own solutions" that are in focus, but always the patient's.
One patient recounted how her life had lost founda- tion when her sister died. The parents, in their pro- longed grief, were unable to give closeness to the child who was left “behind”. She could no longer trust or believe in God, who had not saved her sister from dy- ing. 25 years later she tells of her pain; that in all the years since her sister’s death she has both been angry with God and longed for the divine. She has struggled alone with clarification about what is true for her, and also what she should think about God. It became clear that this has been a part of maintaining her recurrent depression and anxiety. She is clear that my openness to have faith in God in the treatment has been decisive
for her daring to say this, something she had not expe- rienced security for in several previous treatments. It is important to convey that if at any time she asks me to help her to a personal faith in God, I will refer her to another relevant person for such help.
Bringing the patient's existential and religious chal- lenges and resources into the therapy room is crucial for many patients to understand what the challenges are, and for the patient being able to find their healthy solutions. Ask wondering questions about these topics, support and say that you would like to listen to this.
Research supports that existential foundations and re- ligious belief in God are important for people's hope and resilience - and especially for those who struggle with mental illness.
Øystein Elgen is a specialist in psychiatry, senior psychiatrist at Haukeland University Hospital and runs his own specialist practice by appoint- ment to the regional health authority Helse Vest.
Spiritual care in secular healthcare settings
As humans we are challenged by disease both physically and mentally. Facing the existential aspects of these challenges is at the heart of spiritual care.
Ricko Damberg Nissen, Niels Christian Hvidt, Frederik Alkier Gildberg
Historically, spiritual care, that is taking care of the ex- istential, spiritual, and/or religious aspects (henceforth spiritual) of human life in relation to health issues, was traditionally seen as the job of the nurse (who historical- ly used to be nun or deaconess) and the priest. Despite its historical roots in healthcare, the biomedical revolu- tion somewhat pushed it back so that it was not entirely excluded from healthcare, but certainly not an intrinsic or core part of it either. And what was this talk about the spiritual and the religious anyway? Were we not sup- posed to have dispersed of such foolish notions, as we were enlightened by rational thought and progress and an empirical basis for our actions in health care? Suppos- edly so. Yet, as we got busy relegating the spiritual and the religious to the illusory, something else happened.
The spiritual aspects of inmost human life did ‘not go gentle into that good night’, with strong empirical find- ings suggesting unmet spiritual needs. Spiritual care has since again gained momentum.
In recent decades international research has shown time and again, that the spiritual is an intrinsic part of how humans understand their personal health and approach- ing death, and, not the least, how spirituality is an intrin- sic (often imperative) part of how we cope with a crisis situation, such as for instance a terminal or psychiatric
disease. Research from palliative care and nursing is abundant with literature on how important it is to include spirituality in daily care, and research has shown that inclusion of spirituality in day-to- day interactions not only improves quality of life, it also improves health.
This has resulted in somewhat of a conundrum in the secular northern European countries, name- ly an understanding, supported by research, that spiritual care is and should be an integral and im- portant part of healthcare on the one hand, and an ambivalence on how to approach this in daily clin- ical practice on the other hand. We will illustrate this conundrum below, based on findings from a PhD study published in 2019 by the present au- thors. The study was a qualitative study focused on how psychiatrists in Danish psychiatric practice approach religious patients. It was based on inter- views with psychiatrists working in the region of Southern Denmark. 3 quotes from the study will illustrate.
“Religiosity is not really something I look for in a patient” (Informant 13). This quote reflects a common finding in the study and illustrates the mentioned conundrum: religiosity belongs to the
private sphere and is not actively investigated by the psychiatrist. The quote illustrates an indifference from the psychiatrist, and the potential religiosity or spiri- tuality of the patient is not something that the psychi- atrist can use in relation to treatment. For this partic- ular psychiatrist, religion is not only a private area, it is irrelevant.
“If the patient wants to talk about religion that is fine with me, I have no problem with that, but it is not something I bring up, it has to come from the pa- tient” (Informant 10). In this quote, the psychiatrist is open and inviting in relation to religious topics, even though it is still the patient who needs to bring it up.
Again, it is the aspect of privacy the psychiatrist is referring to. However, considering that the kind of privacy that hinders the psychiatrist from approach- ing religion, also applies to the patient, religion might not be an easy topic for the patient to bring up either.
The two quotes illustrate that air of privacy or awk- wardness around spirituality that international re- search has identified as reasons why spiritual care and spiritual coping resources potentially remain dormant and are not brought actively into play.
“It (the patients religiosity) is really good for her (the patient), so I bring it up once in a while when we
Ricko Damberg Nissen, Anthropologist, PhD, Post-doc, Research Unit Psychiatric Hos- pital Middelfart, CPS, Research Unit of General Practice, Uni- versity of Southern Denmark.
Frederik Alkier Gildberg, Research unit forensic mental health psychiatric dept. Middelfart (RFM). At CPS, Psychiatry in the Region of Southern Denmark &
Institute of Regional Health Re- search, Faculty of Health Science, University of Southern Denmark.
development.
Niels Christian Hvidt,
Professor, ThD, Research Unit of General Practice, University of Southern Denmark.
are moving in that area” (Informant 6). This final quote from the study shows a different and more active ap- proach to the religious patient, in an attempt to ac- tivate positive spiritual coping resources (as well as being aware of negative coping resources).
These examples, taken from a study in a psychiatric setting, are emblematic of secular healthcare in gener- al, and illustrate that spirituality is difficult to approach, partly because spirituality is considered a private area, both for the therapist and the patient. However (as il- lustrated in the last quote), there is a growing recog- nition that spirituality is a central way of how we hu- mans deal with crisis. This recognition leads to a new focus on spirituality in daily practice, on assessing and addressing spiritual needs in healthcare settings, and on the development of various forms of spiritual care applicable in secular healthcare settings. Spirituality and spiritual care may well find new ways to surface.
Now, it is up to the healthcare professionals and re- searchers in collaboration to develop ways in which the positive aspects of spirituality can be addressed and brought actively into play, ways through which spiritual care may play an integrated and central part of secular healthcare.
Hope, community
and communities
of hope
Here’s the highway to death and destruction South capitol is its name
And the school just looks like a shit-hole Does that look like a nice place?
Here’s the old mental institution
Now the homeland security base And here’s god’s deliverance center
A deli called M.L.K And the community of hope The community of hope (PJ Harvey, 2016)
Knut Tore Sælør
I’m quite certain that PJ Harvey had different connota- tions in mind when writing the above lyrics than the ones I get when listening to her song. Nonetheless, I’ll use this excerpt as a starting point in this brief piece on hope, and relate it to the field of substance (ab)use and mental health. Thinking back to my nine years as a registered nurse in various psychiatric wards, I don’t think I ever used the word “hope”. It had little to do with either nurs- ing or psychiatry. Instead, the word seemed alienated and difficult to grasp. What’s more, I believe I was afraid of false or unrealistic hopes, when things were indisput- ably uncertain. One of the things I discovered when do- ing a PhD on the phenomenon was that hope is pivotal in times of struggle. It also made me realize that I’m not the only one to find the word challenging to apply in practice. Despite being considered vital, hope received
little attention in the mental health and substance use services where I conducted my studies.
The psychiatric hospital I was part of – like the old mental institution in PJ Harvey’s song – has closed down. Things do change, but often too slowly. And sometimes old institutions take on new shapes and forms. It’s no surprise that people experienc- ing mental health and/or substance use problems still encounter stigma and exclusion. However, I was baffled by some of the descriptions my study participants gave of the thresholds and barriers in services that were supposed to support them.
One of the things that fascinates me with regard to hope is its apparently paradoxical and contra- dictory nature. When the outlook is at its most
We often need to go outside the ranks of doctors to be able to reflect on our own
practice, so we asked a registered nurse with a PhD about his research on hope.
gloomy, hope can appear - seemingly out of nowhere.
The people I interviewed for my PhD underlined the importance of people they can trust, and who have trust in them, whether they are professionals or not.
Price-Robertson, Obradovic and Morgan (2017) have argued: “Experiences such as hope, identity, meaning- fulness and empowerment emerge at the intersections between people, their relationships and environments;
they are best seen as interactional processes rather than states possessed by any one individual” (p. 112).
The psychologist and family therapist Kaethe Weingar- ten (2000) argues that hope is too important to be left to the individual: “Hope must be the responsibility of the community” (p. 402). Weingarten also coined the term reasonable hope. Not only does reasonable hope rely on relations, it is relational in itself. Not something that can be passed on to others, but rather co-creat- ed given the right circumstances. She argues that tra- ditional ways of depicting hope, as opposite ends of a scale, or a dichotomy of hope or hopelessness, do not fit within the chaotic lives people often lead. Rea- sonable hope can co-exist with despair. Sometimes we have to accept a life situation that we could never have imagined. Aiming for picture perfect might result in nothing being done at all. Despite having to settle for second best, we cannot give up on hope. If we aim for the unattainable, hopelessness is likely to grow. If peo- ple are left to choose between hope and hopelessness, chances are they will identify with hopelessness.
Our environment influences hope. Some places leave little hope for change, while others allow it to flourish.
Parallel to Harvey’s lyrics, it matters what conditions you live in. Inequality and socioeconomic factors in- fluence people’s health and can make their outlook bleak. “Shit-hole” schools, lack of suitable housing
or not having a decent paycheck are unlikely to make hope flourish. What may be interpreted as psycho- logical symptoms are often the result of poor material conditions. Rather than seeking a definition of hope that is relevant across different settings, talk about hope needs to consider specific contexts. The future is al- ways uncertain, but can be influenced. Reasonable hope should be considered a verb and a practice, not a noun. It is oriented towards what is here and now and what we can do – together – in order to bring peo- ple in the direction of a preferred future. Being open to the seemingly unexpected is one way professionals convey hope.
Had I returned to an everyday of nursing, I believe I would have used the word hope - or at least the rea- sonable version. I would have been less afraid of unre- alistic or false hopes. As one of the participants I inter- viewed said: hopes may change or you may get new ones. I do believe in having high hopes and goals to strive for. But just as vital I believe is raising the socio- economic standards for those at the bottom of the lad- der and decreasing the inequalities we are well aware of, aiming for a hopeful community or community of hope.
REFERENCES available on request Knut Tore Sælør is a registered nurse with a background from
the field of mental health. He has a masters in clinical health work, and holds a PhD from the Faculty of Psychology, Uni- versity of Bergen, Norway. His thesis was a qualitative study of hope within the context of mental health and substance use services. Currently he is working as an associate professor at the University of South-Eastern Norway, affiliated with the Center for Mental Health and Substance Abuse. He has an interest in qualitative methodology in general, autoethnography in particular, along with how recovery and hope relates to our surroundings.
Hope and resilience in psychoterapy
Per Anders Øien
Endurance is for the soul what the hub is for the wheel;
that which binds it all together (Victor Hugo)
Hope and resilience are two highly important, but, alas, also very abstract, concepts. They are common human factors, but not least vital for patients we meet in our therapy settings. As therapists we probably re- gard it as essential to be able to ‘offer’ patients hope, to convey an idea of a possible better future as a re- sult of therapy and their own efforts. I assume that many of us also have felt a kind of hopelessness in our countertransference, facing the nature and volume of problems that patients share with us. A pitfall for ev- ery therapist is that we may feel tempted to present a hope even before having fully understood and ex- plored the situation the patient is in the middle of. As Søren Kierkegaard, the Danish philosopher, said;
“That when one is truly to succeed in leading a per- son to a certain place, one must first and foremost make sure to find him where he is and begin there.
This is the secret of all auxiliary art. Anyone who does not know it, he himself is an imagination when he thinks that he can help another. In order to truly be able to help someone else, I must understand more than he - but first and foremost understand what he understands.”
In our aspirations to heal or being a successful ther- apist, we may be prone to overlook this. We should have in mind what Hippocrates underlined; ‘never do harm, always console, sometimes soothe, and rarely cure.’ It may sound pessimistic and ‘passive’, but nevertheless more realistic and probably more beneficial to the patient you meet.
I have often felt the heavy burden of the depress- ing experience that the patient’s problems seem so overwhelming that hope appears unachievable. It may lead to a kind of helplessness that it is crucial to be aware of, in order to be able to contain it in stead of acting upon it.
With this challenge in mind, I have often reflect- ed upon the difference between individual thera- py and my work as group therapist. It came to my mind an expression from Irvin Yalom’s eleven group therapeutic factors; instillation of hope. It indicates a level that is something more and above the con- cept of ‘giving’ hope. For some years I ran an ana- lytic group in an acute psychiatric ward. The group met twice a week, and the members were almost
An experienced psychotherapist and the chair of the Psychotherapy section
of the Norwegian Medical Association makes the link between these two
concepts.
never the same. Many of them were admitted short- ly after a suicide attempt, and naturally they were in a state of chaos or despair. As a therapist I was very aware in order to try to turn this despair into a more hopeful position. My experience was that – several times – the fellow patients were able to ‘join in’ and tell the new ones how they themselves had been in a similar situation only short time ago, and – look at me! – now I am able to discuss my problems with oth- ers, I may see the slight light in the end of the tunnel. I often thought that the impact of the peers’ statements seemed to be highly more ‘efficient’ than my efforts as therapist. Probably this is a fundamental both human and therapeutic phenomenon; the experience of not being alone and being understood by another human being. As basic as that.
I have often found myself discussing with my patients the fact that we never know anything about tomorrow or the future in general. We can only assume and it
Per Anders Øien (b 1949), MD, psychiatrist, certified group analyst, IGA Oslo, private specialist prac- tice. Head of the national board of psychotherapy, Norwegian Psychiatric Association.
is worthwhile to reflect upon the possibilities that are present in the not knowing stance. The law of chance may as well bring something positive as something negative. Throw of dices.
Here is in my opinion a link to the concept of resil- ience. Resilience is a rich, viable concept that per- haps mostly is known when working with traumas. I find it very often, regardless of traumas or not, a most useful word to reflect upon. It means the ability to give in when the storm blows, instead of standing firm and erect, which often may lead to a great and abrupt fall. The resilient person has experienced that it may be easier to raise up again, to recover, when the wind has calmed down. The strength in this ability is largely underestimated, and may to a high degree represent the hope that lies in their ability to hold out. This is gold for the soul!
Traumatized Refugees:
How to support their resilience
Traumatized refugees have quite different backgrounds, they are offered different kinds of treatment and show different degrees of resilience.
Marianne Kastrup
Interview with Knud Eschen
How would you characterize the organization in which you work?
The Department for Trauma- and Torture Survivors (ATT) is part of the psychiatric services, Region South- ern Denmark. It is a highly specialized unit, receiving outpatients referred from general practitioners or hos- pital departments. ATT offers packages with differenti- ated, multidisciplinary, holistic assessment and treat- ment to persons diagnosed with PTSD and has a team comprising psychologists, social workers, family ther- apists, physiotherapists, psychiatrist and a nurse. Our target groups are persons with a refugee- or migrant background with legal residence in Denmark who have been traumatized outside Denmark due to war, political persecution, organized violence, torture, etc.
Furthermore, we have a separate unit treating Danish war veterans who have been traumatized in relation to military services outside Denmark.
What comprises the differentiated treatment?
Based upon the complete interdisciplinary assessment the patients are divided into three groups: Those with resp. a high, medium or low level of biological, psy- chological and social resources (including their abili- ty to mentalize). The group with the highest levels of resources is offered individual trauma-focused psy- chotherapy and physiotherapy; the medium group is offered interdisciplinary individual or group therapy with a primarily stabilizing focus, and the group with the lowest levels of resources is referred to an outgo- ing team using a psychoeducational approach. Family
therapy is offered to the groups with resp. medium or high levels of resources.
Do you see any relation between the level of men- talizing and the degree of resilience?
Both yes and no – it is my experience that the background of the refugee plays an important role in the resilience. If the refugee was brought up in a family experiencing basic trust and maybe with an upbringing in a peaceful environment, he/she is better equipped to cope with later violations and may also have a better capacity mentalizing. Others may despite a similar upbringing break down when confronted with the atrocities of war and are later unable to manage their life.
On the other hand, you may encounter – however not frequently - refugees with a childhood marked by war, abuse or violence and little trust and yet the refugee manages later on. I recall a case where a refugee had experienced poor attachment in his upbringing but thanks to the treatment and related trust his mentalizing capacity increased gradually.
And what is important in the contacts between refugees and therapists?
As therapists it is essential that we show empathy but also trust and a dignified approach. We shall allow sufficient time to establish mutual confidence and let the refugees know that we are able to contain their stories. We also find it important to witness the stories that the refugees tell. The testimonial method
can be described as a psychosocial approach, which may improve the emotional wellbeing of the refugees.
We work with the feelings of shame and guilt that many refugees suffer from. It may be survivor guilt or guilt for not having interfered in due course. Shame is also prominent often in relation to a history of sexual assaults.
Another technique is that of reminiscence where you encourage the refugee to tell about positive memories, moments of joy and try to slowly build a link to the present situation and in that way help the person to move on in life. It is important to convey that the ref- ugee is responsible and in charge of his/her own life which increases the resilience.
But how do refugees cope with their present life in Denmark?
Unfortunately, many refugees find their existence in Denmark difficult and with continuing challenges regarding daily life, including navigating the Danish social system. It is my firm impression that the vast majority of the refugees have a genuine wish to work and contribute to their new country and that it would improve their resilience to experience being part of the work-force.
What are the outcome criteria for the therapy?
We have to acknowledge that many are severely trau- matized but a criterion of success is if the patient is capable of managing his/her daily life satisfactorily or taking care of him/herself in a better way. Another cri- terion is if the patient has become more active in the family and taken on his/her role as parent.
You collaborate with Save the Children
Yes, we have in Region Southern Denmark a long-last- ing collaboration with Save the Children and have de- veloped a concept “Experience club”. The clubs are now run by volunteers organizing events in nature for refugee families. We have summer camps where fam- ilies gather at night around a bonfire which facilitates storytelling, maybe the sharing of difficult experiences
Knud Eschen is a family therapist and social worker having worked for many years with traumatized refugees. Department for Trauma and Torture Survivors, Region Southern Denmark
or reflections over the past. You also see e.g. a father and his son fishing and sharing a nice experience for the first time in years. Children experience maybe less restrictions and joyful playing and see their parents in new freer surroundings. I believe that these events increase the resilience of the entire families.
Refugee children and youth – risk and resilience
Psychological problems are frequent in children and youth with a refugee background, but the extent of such problems is reduced over time in exile. Traumatic experiences of war and other organized violence is most important for the short- term reaction of the children, while aspects of life in exile are important for the children’s ability to recover from early traumatization. The quality of the family life furthermore seems to be important for the mental health of the children in both short and long term.
Edith Montgomery
Families who come to Denmark as refugees have of- ten had a past marked by violence, deprivation, inse- curity and anxious waiting. The parents have chosen to flee from areas of war or other forms of organized violence out of a desire and hope to create a better future for themselves and their children in another country. That they have ended up in Denmark is often a coincidence.
Children in traumatized refugee families have often had their own traumatic experiences of, for exam- ple, war, imprisonment, persecution and flight. At the same time, they may have lost or been separat- ed from significant caregivers for a longer period of time if, for example, the father has been at war or in prison, or if one or more family members have died.
Many children have lived in a refugee camp under difficult circumstances before or during the escape, they have experienced shootings, sought protection against bombing, have witnessed killings and assaults
and have had to leave their homes and belongings, often in a hurry. The children react to these experi- ences, for example in the form of anxiety, they may appear sad and upset, suffer from sleep disorders or be unconcentrated, restless and aggressive. How serious the reactions are depends, among other things, on the parents' condition and how quickly and effectively the family is helped to a safer life in exile.
But do the problems persist? Not necessarily. Fol- low-up studies have shown that the magnitude of the psychological problems is considerably re- duced over time, and that the significance of the traumatic experiences before arrival for the chil- dren’s long-time reactions is limited. Most of the refugee children and youth integrate well into the Danish society, go to school, get work, learn the language and get Danish friends. Aspects of stress- ful life circumstances in exile seem to be of utmost
importance for the children’s ability and possibility of recovering from early traumatization.
This does not, however, mean that the traumatic ex- periences are without significance in the long run, but rather that the traumatic experiences from the home country are thrust into the background as other factors get a more direct influence on the child or youth’s mental health. Studies point to following factors as especially important for the long-term psychological reaction of children and youth:
• Aspects of social life in Denmark (including schools, friends and parents’ education and behavior)
• Stressful events in Denmark (including dis- crimination)
The negative factors relate, to a large extent, to the difficulties associated with trying to integrate into Danish society. Networks of friends, supporting insti- tutions and groups, such as schools, can be deciding factors for whether refugees will be able to cope with life in the new society.
Thus, whether or not traumatic experiences have long- Edith Montgomery
Lic. psychologist, PhD, DMSc.
Guest researcher, Danish Research Centre for Migration, Ethnicity and Health, University of Copenhagen
term consequences for the child’s development and mental health depends to a large extent on what hap- pens to the child after arrival in the country of exile.
(Re)establishing a supportive social ecology around the child and his/her family is of prime importance for the healthy adaptation and development. Communi- ty interventions should attempt to establish a secure, predictable, coherent and stable life context within which positive experience can enhance healthy de- velopment. One aspect of such interventions could be to actively combat discrimination and negative attitudes towards refugees within, for instance, the school setting. Some children will need extra support and professional treatment due to their traumatic ex- periences, their social life circumstances and family relations. Interventions aimed at enhancing protective factors and reducing risk factors within the various life contexts of the child will with large probability have a positive influence and might prevent psychopatholo- gy in the long run.
